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VA Form 21-0966 Printable, Fillable in PDF – Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC, is a document that notifies the United States Department of Veterans Affairs (VA) of your intention to file a claim for VA compensation and pension benefits, including the Dependency and Indemnity Compensation (DIC), which is a monetary benefit paid to survivors of service members who died as a result of a service-related disease or injury or as a result of their
It offers the prospective claimant extra time to collect information in support of the claim when the VA Form 21-0966 is submitted. Additionally, it safeguards the earliest possible effective date for any benefits emanating from the filing of the claim. The date on which this form is received by the VA is considered the effective date. The form, on the other hand, must be filed within a year.
The most recent version of the form, which was issued on August 1, 2018, rendered all earlier iterations null and void. Below is a fillable VA Form 21-0966 that may be submitted electronically or downloaded.
Instructions For The VA Form 21-0966
Section I (“Claimant/Veteran Identification”) requires the claimant’s full name, Social Security Number (SSN), and VA file number (if applicable), the veteran’s date of birth, the veteran’s full name, social security number, sex, and service number, the veteran’s current mailing address, the veteran’s telephone number, and the veteran’s email address. Section II (“Claimant/Veteran Identification”) requires the claimant’s full name, Social Security Indicate whether or if you have ever filed a claim with the VA.
In Section II, one or more of the general advantages should be chosen (“General Benefit Election”). It will be impossible for the VA to determine an effective date if the boxes are left unchecked. Survivors’ Pension and/or Dependency and Indemnity Compensation (DIC) must be selected if the claimant is a surviving dependant of the soldier.
In Section III, the claimant expresses his or her intention to apply for one or more general benefits (“Declaration of Intent”). This section acknowledges that this form does not constitute a claim for benefits and that the entire application for benefits must be received by the VA within one year of the date the form is received by the VA. The claimant or their authorized representative must sign the form and make a note of the date on which the claim was filed. If the form was done by a representative from a Veteran Service Organization, an agent, or an attorney, the document must include the name of the person who completed it.
How Do I Submit VA Form 21-0966?
There are three options for submitting the VA Form 21-0966:
- It is possible to enroll online with benefits. To begin, it is required to file a claim with the insurance company. The prospective claimant fills out the personal information page to determine an effective date for the claim. This provides an applicant with one year to finish the application procedure.
- To submit a paper form to the VA pension management center, please click here. Their postal addresses are mentioned here, as well as their telephone numbers.
- In-person or over the phone are both acceptable options. If you have any questions about your benefits, you can contact the VA’s National Call Center or go to one of the VA’s regional benefits offices, which can be found on the eBenefits website.
What Is The Address To Send VA Form 21-0966?
The Philadelphia VA Regional Office serves the states of Connecticut, Delaware, Florida, Georgia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Vermont, Virginia, and West Virginia, as well as all foreign countries that are not served by the St. Paul VA Regional Office. The St. Paul VA Regional Office serves the states of Connecticut, Delaware, Florida, Georgia, and Maine. Forms should be sent to the Department of Veterans Affairs, Claims Intake Center (Attention: Philadelphia Pension Center), PO Box 5206, Janesville, Wisconsin 53547-5206.
Michigan, Mississippi, Missouri, Ohio, Tennessee, and Wisconsin are among the states served by the Milwaukee VA Pension Center. Forms should be sent to the Department of Veterans Affairs, Claims Intake Center, Attention: Milwaukee Pension Center, PO Box 5192 Janesville, Wisconsin 53547-5192.
The St. Paul VA Regional Office covers Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, North Dakota, New Mexico, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, Central America, Mexico, South America, and the Caribbean. Forms should be sent to the Department of Veterans Affairs, Claims Intake Center, Attention: St. Paul Pension Center, PO BOX 5365 Janesville, Wisconsin 53547-5365.